Evaluation and Long-term Management of Neurogenic Bladder in Spinal Dysraphism

An evaluation of onobotulinumtoxinA as a therapeutic option for pediatric neurogenic detrusor overactivity

INTRODUCTION

Neurogenic detrusor overactivity (NDO) results in involuntary detrusor contractions during bladder filling or storage risking transmission of pressure to the upper urinary tracts and/or significant incontinence. The goals of bladder management in children with NDO prioritize the preservation of renal function, prevention of UTIs, and optimizing quality of life. First-line measures include intermittent catheterization and anticholinergic medication. However, when conservative measures fail, surgical intervention may be indicated. Historically, the next step was major reconstructive surgery to create a low-pressure urinary reservoir. The introduction of intravesical botulinum neurotoxin A (BoNT/A) for use in children in 2002 offered a less invasive option for management. However, its exact role is still evolving.

AREAS COVERED

This article summarizes the mechanism of action of BoNT/A for management of NDO and evaluates the current literature defining common practice and clinical efficacy in children with NDO. The findings of the recently completed phase III trial for intravesical onabotulinumtoxinA in children are discussed in detail.

EXPERT OPINION

As the first BoNT/A approved for use in children with NDO, onabotulinumtoxinA appears to be a safe and less invasive alternative to major reconstructive surgery. However, data defining appropriate patient selection and its role as a long-term treatment option continue to develop.

Application of urethral injection of calcium hydroxyapatite as a natural bulking agent for improvement of urinary incontinence in children with spinal dysraphism

PURPOSE

The aim of this report is to evaluate the efficacy of endoscopic injection of calcium hydroxyapatite (CaHA) into the bladder neck and posterior urethra in children with refractory urinary incontinence due to spinal dysraphism.

METHODS

A retrospective study was performed on patients with neuropathic bladder due to spinal dysraphism who had undergone submucosal urethral injections of CaHA from 2010 until 2019. All patients were totally incontinent without voiding per urethra and did not respond to 1-year standard pharmacotherapy with anticholinergic drugs. All children underwent a precise physical exam and urodynamic studies. Patients underwent urethrocystoscopy and injection of pure soluble CaHA into the bladder neck and posterior urethra except for the verumontanum. The outcomes were determined as no change, improvement (social continent), or cure (total continent).

RESULTS

Fifteen children (ten boys, five girls, mean age of 7.6 years) with a history of spinal dysraphism and refractory urinary incontinence were included. Endoscopic injections of CaHA were performed one or two times for each patient. At the median follow-up of 2 years (interquartile range = 6), seven (46.7%), three (20.0%), and five (33.3%) of the patients were total continent, social continent, and total incontinent, respectively. In four patients, intradetrusor botulinum toxin injection was performed simultaneously with CaHA injection. Also, one patient experienced a febrile urinary tract infection between two CaHA injections. Among 15 patients, 9 had atonic/hypotonic bladders both before and after CaHA injections; at the last follow-up, 4 of these children (44.4%) were totally continent. No injection-related or other complications were observed in the patients.

CONCLUSION

Injection of CaHA into the bladder neck is relatively safe, reproducible, and effective for total dribbling urinary incontinence in children with spinal dysraphism. The bladder neck reconstruction with or without a urethral sling or other surgical procedures could be postponed until puberty in selected cases. However, further multicenter clinical trials are highly recommended.

Rehabilitation care of patients with neurogenic bladder after spinal cord injury: A literature review

This article reviews the research progress of rehabilitation treatment and nursing care of patients with neurogenic bladder after spinal cord injury, in order to provide reference for the rehabilitation treatment and nursing care of patients. We reviewed recent medical literature on patients with neurogenic bladder, focusing on neurogenic bladder caused by spinal cord injury. We analyzed 30 recent of publications in patients with neurogenic bladder after spinal cord injury, in addition to reviewing and evaluating the commonly used rehabilitation nursing methods for neurogenic bladder. Psychological counseling is a vital aspect which cannot be neglected in the process of neurogenic bladder rehabilitation. Hitherto, the commonly used drug and surgical treatments may have negatively impacted the mental health of patients in varying degrees. However, in clinical practice, applying intermittent catheterization in patients who have neurogenic bladder with spinal cord injury may help improve patients’ life quality, mitigate psychological burden, and reduce negative emotions.

Sacral Spina Bifida Occulta: A Frequency Analysis of Secular Change

Substantial relaxation of natural selection beginning around 1900 changed the mutation/selec­tion balance of modern genetic material, producing an increase in variable anatomical structures. While multiple structures have been affected, the temporal increase in variations of the sacrum, specifically, ‘Sa­cral Spina Bifida Occulta,’ have been reliably demonstrated on a localised scale. Calculation of largescale frequency has been hindered by the localised nature of these publications, the morphological variability of this variation, and potential pathological associations, which have produced divergent classifications, and conflicting reported rates of occurrence. A systematic review of the reported literature was conducted to provide an objective analysis of Sacral Spina Bifida Occulta frequency from 2500 BCE to the present. This review was designed to compensate for observed inconsistencies in reporting and to ascertain, for the first time, the temporal trajectory of this secular trend. A systematic review of Sacral Spina Bifida Occulta lit­erature was conducted through the strict use of clinical meta-analysis criteria. Publications were retrieved from four databases: PubMed, Embase, the Adelaide University Library database, and Google Scholar. Data were separated into three historical groups, (1 = <1900, 2 = 1900 to 1980 and 3 = >1980), and frequency outcomes compared, to determine temporal rates of occurrence. A total of 39/409 publications were included in the final analysis, representing data for 16,167 sacra, spanning a period of 4,500 years. Statistically significant results were obtained, with total open S1 frequen­cy increasing from 2.34%, (79 to 1900CE), to 4.80%, (1900 to 1980CE) and to 5.43% (>1980CE). These increases were significant at p<0.0001, with Chi-squared analysis. A clear secular increase in the global frequency of Sacral Spina Bifida Occulta has been demonstrated from 1900 to the present. This research provides a novel and adaptable framework for the future assessment of variation distribution, with impor­tant implications for the fields of biological anthropology and bioarchaeology.

Upper urinary tract function of patients with multiple sclerosis

BACKGROUND

Neurogenic lower urinary tract dysfunction (NLUTD) is frequent in multiple sclerosis (MS) and renal prognosis is a key point of bladder management.

OBJECTIVE

To assess upper urinary tract damage risk using voiding cystourethrography (VCUG) in patients with (PwMS) and NLUTD.

METHODS

We conducted a retrospective study between 2010 and 2020. Demographic data, urinary symptoms, urinary tract infection (UTI), renal ultrasounds findings, glomerular filtration rate (GFR), VCUG data, and urodynamic parameters were collected in PwMS with NLUTD.

RESULTS

Among 325 PwMS included, 67% were female, mean age was 51.6 ± 12.0 years, and mean EDSS 4.6 ± 1.8. VCUG showed vesicoureteral reflux (VUR) in 18 patients. A link was found between VUR and progressive MS course (p = 0.04), hydronephrosis (odds ratio [OR] = 17.44; 95% confidence interval [CI] = 3.46-87.87; p = 0.001), low GFR (p < 0.001), and detrusor overactivity (p = 0.04). No association with UTIs, EDSS, detrusor sphincter dyssynergia, were elicited. On multivariate analysis, alteration of GFR was independently related to the presence of VUR (OR = 0.95; 95% CI = 0.92-0.98).

CONCLUSIONS

VUR elicited on VCUG is associated with lower GFR and hydronephrosis. However, due to the low prevalence (5.5%) of this abnormality in PwMS, VCUG should be performed in selected cases and not in routinary practice.

[Effectiveness and safety of sacral neuromodulation on neurogenic bladder and bowel dysfunction in patients with spina bifida]

Objective

To evaluate the effectiveness and safety of sacral neuromodulation (SNM) in the treatment of neurogenic bladder and bowel dysfunction in patients with spina bifida.

Methods

The clinical data of 33 patients with neurogenic bladder and bowel dysfunction caused by spina bifida treated with SNM between July 2012 and May 2021 were retrospectively analyzed. There were 19 males and 14 females, with an average age of 26.0 years (range, 18.5-36.5 years). The disease duration ranged from 12 to 456 months, with an average of 195.8 months. The types of spina bifida included 8 cases of occult spina bifida and 25 cases of meningocele/myelomeningocele. Clinical symptoms included 19 cases of urgency-frequent urination, 18 cases of urinary incontinence, 27 cases of chronic urinary retention, and 29 cases of bowel dysfunction. Image urodynamics showed that 4 patients had detrusor overactivity (DO) and 29 patients had detrusor underactivity (DU). Vesicoureteral reflux (VUR) was found in 5 ureters (4 patients). SNM procedure was divided into experiential treatment and permanent implantation. Patients who were evaluated as successful or willing to be permanently implanted after experiential treatment would implant the permanent pulse generator.

Results

The duration of experiential treatment was 14-28 days, with an average of 19.2 days; there was no complication during this period, and the overall success rate was 69.69% (23/33). At the end of experiential treatment, the urination frequency in 24 hours, urine volume per time, urinary urgency score, and urine leakage of patients were significantly improved when compared with those before experiential treatment ( P<0.05); there was no significant difference in postvoid residual volume between before and after experiential treatment ( t=1.383, P=0.179). The success rate of patients with chronic urinary retention after experiential treatment (25.93%) was significantly lower than that of urgency-frequent urination (63.16%) and urinary incontinence (61.11%) ( χ ²=7.260, P=0.064). Compared with those before experiential treatment, the maximum cystometric capacity and compliance increased and the maximum detrusor pressure during filling decreased significantly ( P<0.05). Among the 4 patients with DO before experiential treatment, DO disappeared in 2 cases; 27 patients with DU before experiential treatment did not recover the normal contraction of detrusor during micturition. Among the 5 ureters with VUR before experiential treatment, 2 VUR disappeared at the end of experiential treatment, and the VUR grade or the bladder volume before VUR of the other 3 ureters were improved. At the end of experiential treatment, the neurogenic bowel dysfunction (NBD) score and the grade of bowel dysfunction significantly improved ( P<0.05). A total of 19 patients received permanent implantation, of which 11 patients needed to empty the bladder in combination with intermittent catheterization.

Conclusion

SNM is effective for neurogenic bladder and bowel dysfunction in patients with spina bifida. At the same time, it can significantly improve the urodynamic parameters during urine storage and avoid upper urinary tract damage.

Effectiveness of Acupuncture on Urinary Retention: A Meta-Analysis

Objectives

This study aimed to evaluate the safety and efficacy of acupuncture in the treatment of urinary retention (UR).

Methods

Randomized controlled trials investigating the effectiveness of acupuncture in the treatment of UR were identified by searching seven comprehensive databases (Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database, and Chinese Biomedical Literature Database) prior to September 2020. Data analysis was performed using RevMan, version 5.3, and Stata software, version 14.0.

Results

A total of 12 studies with 979 participants were included. A random-effects model was used to conduct a meta-analysis on the acupuncture group and the control group. The results show that acupuncture can effectively promote spontaneous urination and reduce anxiety in patients with poor urination (relative risk: 1.35; 95% confidence interval (CI): 1.19–1.53; P < 0.00001). The random-effects model showed significant differences in residual urine volume between the acupuncture group and the control group (MD: −84.79, 95% CI: −135.62 to −33.94; P=0.001).

Conclusion

Acupuncture is safe and effective in the treatment of UR. However, since the current level of evidence is limited, high-quality, large-sample, multi-center, clinical randomized controlled trials are needed to further confirm our conclusions in the future.

Efficacy and safety of electrical stimulation in the treatment of neurogenic bladder dysfunction in myelomeningocele-Systematic review of randomized clinical trials

AIMS

The purpose of this systematic review was to investigate and synthesize the effects (benefits and harms) of electrical stimulation (EE), alone or in association with other interventions, compared with sham and other interventions, for the treatment of neurogenic bladder dysfunction in myelomeningocele.

METHODS

This systematic review was conducted following the methodological recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and registered at PROSPERO (CRD42020200425). A search was performed in the following electronic databases: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, LILACS, and PEDro. Randomized clinical trials (RCTs) that assessed any EE in children diagnosed with myelomeningocele and neurogenic bladder and/or urinary incontinence were included and reported.

RESULTS

When comparing EE versus sham groups, some estimated effects showed a wide confidence interval, probably due to the small sample size of the included studies. This indicates an imprecision in these findings. Regarding the safety of this intervention and safety of the lower urinary tract, no adverse events resulting from EE were reported. All the included studies have evaluated the efficacy of EE compared with sham, but different EE parameters and electrode positions among studies make it impossible to perform a meta-analysis.

CONCLUSIONS

Based on very low certainty evidence, the findings of this systematic review suggested no difference between EE and sham to improve urinary incontinence in children with myelomeningocele. However, the small sample size and the imprecision arising from the wide confidence intervals must be considered. Future RCTs following a rigorous methodology, as recommended by the CONSORT statement, should be conducted to support the use of this intervention in clinical practice.

Non-invasive markers in the management of pediatric neurogenic bladder over the last two decades - A review

Neurogenic bladder (NB) is one of the most challenging problems in nephro-urological management in pediatrics. It is an important risk factor of secondary upper urinary tract damage. A complete clinical evaluation is necessary and requires life-long extensive medical attention including invasive procedures that affect patients' quality of life. Potential non-invasive biomarkers would be desirable, especially in the pediatric population. The aim of this review was to analyze two decades of data regarding potential non-invasive biomarkers in the assessment and follow-up of children with NB. This paper summarizes and appraises the knowledge about both biochemical and imaging-based markers in 3 aspects: markers of urinary tract infections (UTIs), bladder and renal function, and this paper looks at their prospective application in everyday clinical care.

The Effect of Sacral Neuromodulation in Ambulatory Spina Bifida Patients with Neurogenic Bladder and Bowel Dysfunction

OBJECTIVE

To assess the effect of sacral neuromodulation (SNM) in ambulatory spina bifida patients with neurogenic bladder and bowel dysfunction.

MATERIALS AND METHODS

We retrospectively reviewed the records of 29 ambulatory spina bifida patients with neurogenic bladder and bowel dysfunction who underwent SNM testing from July 2012 to January 2020. Clinical data and video-urodynamic parameters were collected and compared using the t-test and the chi-square test. The potential risk factors were considered by logistic regression analysis. P < .05 was considered significant.

RESULTS

In the test phase, 21 patients (72.4%) achieved successful improvement of at least 1 symptom. The success rate for chronic urinary retention (26.09%) was significantly lower (P <.05) than that for urgency-frequency syndrome (58.82%) and urinary incontinence (56.25%). The mean neurogenic bowel dysfunction score decreased from 13.3±6.29 to 6.9±5.09 (P <.0001). The urodynamic evaluation showed a significant improvement in the mean maximum cystometric capacity, compliance, and maximum detrusor pressure (P <.05). Implantation was performed in 16 cases (55.17%). The analysis of the risk factors showed that chronic urinary retention was a statistically significant variable (P <.05). No complications were reported in the test phase. The average follow-up time was 41.19±33.06 months. Two patients changed to intermittent catheterization, and 2 patients changed to augmentation cystoplasty.

CONCLUSION

SNM is effective for neurogenic bladder and bowel dysfunction in patients with ambulatory spina bifida, especially in those without chronic urinary retention. And SNM can also significantly improve the urodynamic parameters of these patients during the storage period.

Four-hour voiding observation with provocation test reveals significant abnormalities of bladder function in newborns with spinal dysraphism

INTRODUCTION

Four-hour voiding observation with provocation test (VOP) using a scale, a damp detector and ultrasound for determination of residuals, is an easily performed non-invasive method for the evaluation of bladder function in newborns. Neonatal bladder function evaluated with VOP has been described for healthy newborns (HN) but not for children with spinal dysraphism (SD), for whom early bladder evaluation is essential for decisions regarding Clean Intermittent Catheterization and follow-up. The aim of the present study was to describe voiding observation with provocation test in newborns with spinal dysraphism and compare with corresponding data for healthy newborns.

METHODS AND MATERIALS

At a tertiary hospital, a 4 h voiding observation with provocation (VOP) was performed in 50 neonates (22 girls, 28 boys) with spinal dysraphism (37 open SD, 13 closed SD) consecutively evaluated for possible neurogenic bladder-sphincter dysfunction (1998-2019). All newborns with open SD and 4/13 with closed SD had been through postnatal neurosurgery before the test. Mean age was 10 days. Voiding observation was performed during 4 h with visual observation the fourth hour recording behavior and urinary flow (e.g. stream, dribbling). Finally, bladder provocations (e.g. suprapubic compression) were performed, and any leakage was noted. Findings were compared to those of 50 healthy newborns (HN) earlier published (Gladh et al., 2002). There were no significant differences in background data such as gender, age or diuresis between newborns with SD and HN.

RESULTS AND DISCUSSION

Voiding observation with provocation test of children with SD revealed significant differences compared to HN see summary table. Some children with SD had frequent small voids/leakages and low bladder volumes while three had no voiding and high volumes. Leakage during bladder provocation test and not voiding with a stream was not seen in HN but were common in newborns with SD (69% resp. 74%) (p < 0.01). A child with these findings should thus be investigated further. Identifying children needing Clean Intermittent Catheterization is important as well as being able to postpone or refrain from invasive urodynamic studies if not strongly indicated. VOP may give valuable information for these judgements.

CONCLUSION

Newborns with spinal dysraphism differ from healthy newborns in many aspects of bladder function. Bladder function varies between newborns with closed and open spinal dysraphism. Many newborns with spinal dysraphism leak at bladder provocation and void without a stream but healthy newborns do not. Early determination of post-void residuals is mandatory in children with spinal dysraphism and non-invasive VOP gives this information in a standardized way, also adding information on frequency, voiding with a stream and leakage at provocation.